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 ARCHIVES
TRAUMA-LISTABDOMINAL
TRAUMA |
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Diagnostic Peritoneal Lavage
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From: Andrew Bowman, List members, I attended a trauma conference this year where the pros and cons of diagnostic peritoneal lavage (DPL) were presented. The presenting physician advocated that there is still a time/place for DPL. I know that FAST exams are becoming popular and almost a standard at Level I centers but my community hospital does not have this luxury yet. My question is this, are any list members out there still using DPL and if so what is the scenario in which you would use it? I have been trying to promote its use when we have a head/abdomen blunt trauma victim and use DPL to screen quickly for intraperitoneal blood and decide if head CT can happen next or wait until after OR for abdomen but my hospital is a "CT hospital" and so off all the patients go to CT. Any comments, thoughts or suggestions? And if you do promote DPL in certain situations how can I spread the word convincingly? Thank you, Andrew J. Bowman, RN, CEN, CCRN, NREMT-P
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From: Avi Roy Shapira, I use DPL almost exclusively in the OR. The scenario is often the following: An MVA victim, compound long bone fratures. Fast negative and patient stable. Orthopods take to OR to fix fractures. Mess around a while, BP drops. Ortho guys deny they are losing blood, Anesthesia call us. We do a DPL. It is negative. Anesthesia gives blood. Patient stable again. We leave. Avi
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From: Robert F. Smith, MD At Cook County Hospital we use DPL routinely. We use it in unstable or not physiologically normal patients to determine if there is blood in the peritoneal cavity (100,000 rbc ) and the patient should go for a laporotomy. Patients like these are not suitable for transport away from the resuscitation area to the CT scanner. If you take these type of patients to CT I'm surprised you don't have a wealth of Morbidity and Mortality data which is really convincing. At County one of our big sources for M&M is patients who were thought to be stable enough to go to CT but really weren't. FAST would give the same information as DPL. We also use it for anterior abdominal stab wounds to select out patients likely to have an abdominal injury ( 100,000 rbc ) and will eventually demonstrate peritonitis or instability. Lastly we use it to determine if the peritoneal cavity has been penetrated; unclear path of bullet or back and/or flank penetrating trauma or possible diaphragmatic violation from a stab wound. The rbc count here is 10,000. FAST will not give you this information. Robert F. Smith, M.D.,MPH
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From: Jan Nijs, MD Dear Andrew, Since a few years, in the trauma setting, Europe is very US (ultrasound) minded in evaluating the presence of free abdominal fluid (intestinal contents, blood). However, in my experience, US is very operator-dependent. I’ve seen abdominal cavities full of blood, after a completely negative abdominal US and vice versa. For that reason, me and my collegues didn’t abandon completely the use of DPL in the trauma setting, contrarily. Situations in which-in my opinion- a liberal use of DPL is justified (versus obligatory) are: -craniocerebral trauma patients who are tachycard or hypovolemic, in which the abdominal physical examination is difficult to evaluate (unconscious patients e.g.) -Any traumapatient who is hypotensive (hypotensive = hypovolemic until proven otherwise; other causes of hypovolemia have to be excluded), regardless if an US has been performed and regardless the result of the DPL. Any of these patients with a (frankly) positive DPL is taken immediately to the OR for an abdominal exploration, without having performed a CT scan (head or abdomen). Taking a hypotensive patiënt to radiology for scanning the head or abdomen is considered a medical error and unnecesarily prolongs the door-to-OR time (if you ever arive in the OR at all). Personally, I’ve never seen a good outcome (= patiënt alive) by taking a hypotensive trauma victim to CT scan, which is not situated directly near to the OR or ED in our hospital (i.e. 200 meters and one elevator away from the shock room) Therefore I personally promote the liberal use of DPL in these patients. Hope this might be usefull information to you. Kindly yours, |
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From: Beverley Fink, RN Attached is our protocol for penetrating trauma. We still use DPL-we have ultrasound respond to all Step I traumas but do DPL depending on the location of the wound. The references used to develop this protocol are as follows: Elliott DC and Militello P. Pitfalls in the Diagnosis of Abdominal Trauma. In Maull et al (eds). Complications in Trauma and Critical Care, Saunders (Philadelphia), 1996. Pages 145-158. Eastern Association for the Surgery of Trauma. Practice Guidelines for the Non-Operative Management of Blunt Injury to the Liver and Spleen. http://www.east.org/tpg.html, 1998 American College of Surgeons, Committee on Trauma Resources for Optimal Care of the Injured Patient: 1999 American College of Surgeons, Committee on Trauma. Evaluation of Abdominal Trauma, 1995 Waters JB et al Development and Implementation of Clinical Standards for the Management of Four Trauma Diagnoses. J Healthcare Quality 1998; 21:3 Hope this helps. Bif Fink, RN
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From: Dan Caruso, MD Andrew, I would agree with everyone who is contributed back to you regarding DPL... And we, like Cook County, use it more and more... I think, DPL best used in the hemodynamically unstable patient... If postive, must go to OR... However, please refer to Dr. David Wisner article of a few years back, J. Trauma (sorry, don't remember the year), that in the situation of a patient with a head injury and abdominal injury... and the question of whether CT of Head is needed prior to OR... he showed that if patient with "localizing signs" needs CT of Head if possible, even in face of abdominal wound due to localizing head injury having potential to kill patient... Now, when pt with bad head injury and of course bad abdominal injury... well that is when life sucks for the trauma surgeon... my choice there is to the OR and try to persuade Neurosurgeon to place ventric etc... (although if no CT, obviously hard to know what to exactly to do in the OR) ... If you're lucky you can pack abdomen and control things and then get quick CT... but once again... in the setting of bad injury with localizing signs... need to evaluate the head And I agree that FAST is quicker and maybe better but if you perform a FAST: 1) I think it should be used in the same patient population as DPL... the unstable... 2) And if you are using FAST you must be willing to operate on the findings Otherwise if you use the FAST and see free fluid, but in the stable patient, why FAST? I suppose you could operate, and I've done that... end up operating on lots of stuff you should have watched... or you end up at CT anyway... Food for thought!
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From: Peter Thompson Use of FAST has its benefits for repeating scans to evaluate changes in condition and correlate with clinical findings. It has become more popular both in parts of Australia and UK. Operator dependent - sure but so is DPL- if performed poorly it is easy to get a false positive result for blood. DPL still has a role for those unable to get suitable FAST image as well as determining bowel perforation (Experience in many units in UK and Australia still proceed with early surgery in this group of patients). Though use of DPL has reduced over past 5 years we still ensure that ED and trauma doctors are competent in its practice as it remains a helpful tool in patient evaluation. Regards, Peter Thompson
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From: Avi Roy Shapira The question was DPL in the FAST era. In the case of unstable patients, FAST is better and fasterthan DPL. Stab wounds are explored based on instability or peritoneal signs. Neither FAST nor Positive DPL are as good as clinical serial observations. Avi
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From: Robert F. Smith MD Avi, I'm not aware of any literature that shows FAST is better than a DPL. I believe FAST is more operater dependant than DPL as one of the other posters said. It is certainly quicker in skilled hands. Regarding stab wounds, we attempt to identify early those patients that will procede to develop peritonitis in the belief that it is better to intervene earlier than later. Rob Smith |
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From: Avi Roy Shapira, FAST is still a better test for the following reasons: 1. It is cheaper, if done by the surgeon. You can buy a good US machine these days for less than 10K. A DPL kit costs around 170$ here (Arrow). So 60 DPL's covers the cost of the machine and the goop, and I have not figured in the cost of the cell count. 2. You can also check for fluid in the pericard. Something you can't do with DPL. 3. It is non-invasive. So it does not hurt the patient - even local anesthsia injection is not something you want to have if you don't have to. In addition, we have all seen the occasional iatrogenic injury from DPL. It is uncommon, and almost always minor, but don't you hate doing a laparotomy only to find that the positive DPL was from a nicked mesenteric or omentic vessel caused by the needle? Or a wound infection at the incision, if you use the open technique. 4. It is faster. Even in skilled hands, preping, covering, infiltrating local anesthesia, insering the catheter, getting the liter of fluid in, and getting it back, takes at least 10 -15 minutes. It may be longer if you do open DPL's or have to wait for the RBC count. FAST takes up to 5 minutes, but in the great majority of positive tests it takes only a minute or two, becasue it is easy to see the blood in Morrison's pouch, and these are the patients where speed counts. It is true that in these patients DPL is also faster, since you may get a positive tap. But a positive tap has a high false positve rate. If you have two tests that yield equal information, but one is cheaper, more convenient and gets the results faster, which would you prefer? Get on the wagon. Once you start doing FASTs you will never go back to DPL. The key is to do them yourself. If you rely on radiology, the test becomes more expensive, and takes longer. The learning curve for FAST is very quick. Although we taught them, our residents now do it much better then the attendings. Avi
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From: Kimberly Nagy MD, FACS FAST is as good as DPL in unstable patients with BLUNT trauma. THat is, of course, assuming that the surgeon has been trained in FAST which is true in more and more trauma centers. FAST is however, not useful in ruling out need for operation in PENETRATING trauma. DPL with a lower RBC threshold can see blood that FAST cannot. ie. 10,000 RBC = 2 cc. of blood, 20,000 = 4 cc., etc.etc. In patients with a hollow viscus or diaphragm injury, there may not be enough blood to see via FAST. Serial examination will pick up those with visceral injury but is associated with delay to operation. Personally, I prefer to know if my patient needs an operation soon after admission rather than waiting for peritonitis. I think the patients prefer it as well. Kimberly Nagy, MD FACS
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From: Avi Roy Shapira All is true. But do these patients need a DPL? You agree that: > Serial examination will pick up those with visceral injury but you argue that it will delay the operation. This is true, but what gives? The visceral injuries that serial exams pick up are small. The delay is at most a few hours (if you have a good protocol, and follow it rigidly) and in large series, has not been found to harm the patients. A negative or nontherapeutic laparotomy has a significant complication rate. If you operate with a low threshold, you will have a high rate of nontherapeutic laparotomies. Since all a low threshold proves is penetration. Hopefully, you know that already from the local wound exploration. If you operate with a high threshold, FAST is just as good, and does not interfere with subsequent serial exams. Avi |
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From: Sigard Golum, Greetings, just want to remind some people that a positive DPL in a stable patient means nothing. Actually it means that the patiente should go to CT. Now we know that many hepatic and spleen injuries can be treated without surgery.I think that DPL should only be used if you don't have US, you don't trust your US operator or US results are inconclusive (all in the unstable patient. No room for DPL in the stable patient)
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From: Eric Frykberg, MD FACS Simple-- The inability to do U/S is an indication to do DPL--its original indications, accuracy and safety still stand--just unnecessary if U/S is available and expertise to use it available ERF
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